ARC Staff Injury and Illness Record

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Staff Injury and Illness Record

DR#	DR Name:	Date of Disaster:
Today's Date:	Volunteer Employee	Inprocessing Date:
Group/Activity/Position & work Location:
Staff Lodging Location:	Outprocessing Date:	Number of workdays Lost:
Chapter:		City/State:

PERSONAL INFORMATION

Last Name: First Name: DSHR# :

Date of Birth: Age:

Male Female

Street Address:

City:

State: Zip:

Home Phone # :

ARC Cell Phone # :

ILLNESS REPORT

Past Medical History
Current Problem/ Signes & Symptoms / Condition:	Illness Injury
Current Medications:
Allergies:	NKDQ Yes Specify:
Hospitalized	No Yes Date admitted: Date Released:
Treated by E.R, Clinic or provider No Yes	Treated by Staff Health only, no referral Other
Treating Facisility or Health Care Providr : Name Address, Phone Number
CATEGORY OF ILLNESS (Check only one) Respiratory Gastro-intestinal Cardiovascular Diabetic-related Asthma Rash Dental Heat-related Other	NOTES: Describe event, treatment, and follow-care. (Date, time and sign each entry)
Insurance claim/ Worker’s Compensation filed Date: Claim#:
Outprocessed for health/mental reason Date:
Chapter notified of outprocessing: Yes No Activity Manager notified: Yes No
Staff Services Administrator notified: Yes No Operations Management (OM) notified: Yes No

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Staff Injury Illness Record

Presumed Parent / Guardian Information

SOURCE OF INJURY
(Check only one)

TYPE OF INJURY
(Check only one)

TYPE OF ACCIDENT
(Check only one)

BODY PART(S) INJURED

WHAT ACTIONS AND CONDITIONS CONTRIBUTED TO THE ACCIDENT?
IMMEDIATE CAUSE

CONTRIBUTING CAUSES:

WITNESS INFORMATION (Name & Contact Information):

REVIEWED WITH SUPERVISOR? Yes No

DESCRIPTION OF ACCIDENT: (Date, time and sign each entry)